1
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Odackal NJ, Crume M, Naik T, Stiver C. Cardiac Development and Related Clinical Considerations. Neoreviews 2024; 25:e401-e414. [PMID: 38945970 DOI: 10.1542/neo.25-7-e401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/27/2024] [Accepted: 03/06/2024] [Indexed: 07/02/2024]
Abstract
The anatomy, physiology, and hemodynamics of the premature heart vary along the range of gestational ages cared for in neonatal intensive care units, from 22 weeks to term gestation. Clinical management of the preterm neonate should account for this heterogenous development. This requires an understanding of the impact of ex utero stressors on immature and disorganized cardiac tissue, the different state of hemodynamics across intracardiac shunts impacting the natural transition from fetal to neonatal life, and the effects of intensive pharmacologic and non-pharmacologic interventions that have systemic consequences influencing cardiac function. This article provides a review of the increasing but still limited body of literature on the anatomy, hemodynamics, and electrophysiology of the preterm heart with relevant clinical considerations.
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Affiliation(s)
- Namrita J Odackal
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Mary Crume
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Tanvi Naik
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Corey Stiver
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Division of Cardiology, Nationwide Children's Hospital, Columbus, OH
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2
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Varghese NP, Altit G, Gubichuk MM, Siddaiah R. Navigating Diagnostic and Treatment Challenges of Pulmonary Hypertension in Infants with Bronchopulmonary Dysplasia. J Clin Med 2024; 13:3417. [PMID: 38929946 PMCID: PMC11204350 DOI: 10.3390/jcm13123417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
Advances in perinatal intensive care have significantly enhanced the survival rates of extremely low gestation-al-age neonates but with continued high rates of bronchopulmonary dysplasia (BPD). Nevertheless, as the survival of these infants improves, there is a growing awareness of associated abnormalities in pulmonary vascular development and hemodynamics within the pulmonary circulation. Premature infants, now born as early as 22 weeks, face heightened risks of adverse development in both pulmonary arterial and venous systems. This risk is compounded by parenchymal and airway abnormalities, as well as factors such as inflammation, fibrosis, and adverse growth trajectory. The presence of pulmonary hypertension in bronchopulmonary dysplasia (BPD-PH) has been linked to an increased mortality and substantial morbidities, including a greater susceptibility to later neurodevelopmental challenges. BPD-PH is now recognized to be a spectrum of disease, with a multifactorial pathophysiology. This review discusses the challenges associated with the identification and management of BPD-PH, both of which are important in minimizing further disease progression and improving cardiopulmonary morbidity in the BPD infant.
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Affiliation(s)
- Nidhy P. Varghese
- Department of Pediatrics, Division of Pulmonology, Baylor College of Medicine and Texas Children’s Hospital, 6701 Fannin St., Ste 1040, Houston, TX 77030, USA
| | - Gabriel Altit
- Division of Neonatology, Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada;
| | - Megan M. Gubichuk
- Division of Pulmonary and Sleep Medicine, Children’s Mercy Hospital, Kansas City, MO 64108, USA;
| | - Roopa Siddaiah
- Department of Pediatrics, Penn State Health Children’s Hospital, Hershey, PA 17033, USA;
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3
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Boyd SM, Kluckow M, McNamara PJ. Targeted Neonatal Echocardiography in the Management of Neonatal Pulmonary Hypertension. Clin Perinatol 2024; 51:45-76. [PMID: 38325947 DOI: 10.1016/j.clp.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Pulmonary hypertension (PH) in neonates, originating from a range of disease states with heterogeneous underlying pathophysiology, is associated with significant morbidity and mortality. Although the final common pathway is a state of high right ventricular afterload leading to compromised cardiac output, multiple hemodynamic phenotypes exist in acute and chronic PH, for which cardiorespiratory treatment strategies differ. Comprehensive appraisal of pulmonary pressure, pulmonary vascular resistance, cardiac function, pulmonary and systemic blood flow, and extrapulmonary shunts facilitates delivery of individualized cardiovascular therapies in affected newborns.
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Affiliation(s)
- Stephanie M Boyd
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Corner Hawkesbury Road, Hainsworth Street, Westmead, Sydney 2145, Australia; The University of Sydney, Sydney, Australia
| | - Martin Kluckow
- The University of Sydney, Sydney, Australia; Department of Neonatology, Royal North Shore Hospital, Reserve Road, St Leonards 2065, Sydney, Australia
| | - Patrick J McNamara
- Division of Neonatology, The University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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4
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Zhu F, de Oliveira CB, Mohsen N, Kharrat A, Deshpande P, Mertens L, Jain A. Challenges in clinical identification of right ventricular dysfunction in preterm infants with persistent pulmonary hypertension of the newborn. Early Hum Dev 2024; 190:105942. [PMID: 38306954 DOI: 10.1016/j.earlhumdev.2024.105942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/20/2023] [Accepted: 01/11/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Right ventricular dysfunction, typically qualitatively diagnosed (Q-RVd) in preterm infants, requires echocardiography which is not always acutely available. We aimed to identify clinical indices of Q-RVd in very preterm infants (gestational age, GA <32 weeks) with persistent pulmonary hypertension of newborn (PPHN) and examine the reliability and validity of Q-RVd. METHODS Forty-seven infants with mean ± SD GA of 26.8 ± 2.7 weeks who had targeted neonatal echocardiography (TNE) ≤72 h old, during PPHN, were retrospectively studied. Three standard TNE clips were reviewed by two blinded assessors, and infants categorized as Q-RVd if moderate-severe RVd was diagnosed on ≥2 clips. Cardiopulmonary clinical indices at TNE and quantitative RV functional markers were compared between Q-RVd vs. no-RVd groups. Potential quantitative RVd definitions examined by classifying each measurement as "low" or "normal" using published data. Inter-rater agreement for Q-RVd assessed using Kappa statistics. RESULTS Mean age at TNE was 25.3 ± 20.4 h with Q-RVd diagnosed in 19(40 %) infants. Q-RVd group demonstrated higher peak oxygen requirements (96 ± 9 % vs. 84 ± 16 %, p < 0.01); however, no clinical parameters at TNE differentiated the groups. Quantitative measures were lower in Q-RVd patients, confirming classification validity. Among tested quantitative definitions, low RV stroke volume was associated with lower systolic blood pressure (41±7 vs. 47±9 mmHg, p = 0.02) and higher shock index (4.02±0.80 vs. 3.44±0.72, p = 0.02). Kappa for Q-RVd was 0.55 (95%CI 0.32-0.77). CONCLUSIONS The non-specific nature of clinical markers of RVd in preterm infants with PPHN necessitates echocardiographic diagnosis of RVd. Studies should examine prognostic relevance of RVd and establish outcome-based quantitative definitions in preterm infants.
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Affiliation(s)
- Faith Zhu
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Ontario, Canada
| | - Caio Barbosa de Oliveira
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Ontario, Canada
| | - Nada Mohsen
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Ontario, Canada; Department of Pediatrics, Mansoura University, Mansoura, Egypt
| | - Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Ontario, Canada
| | - Poorva Deshpande
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Ontario, Canada
| | - Luc Mertens
- Department of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Ontario, Canada.
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Feasibility, Reproducibility and Reference Ranges of Left Atrial Strain in Preterm and Term Neonates in the First 48 h of Life. Diagnostics (Basel) 2022; 12:diagnostics12020350. [PMID: 35204441 PMCID: PMC8871374 DOI: 10.3390/diagnostics12020350] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 11/17/2022] Open
Abstract
Left atrial strain (LAS) is the most promising technique for assessment of diastolic dysfunction but few data are available in neonates. Our aim was to assess feasibility and reproducibility, and to provide reference ranges of LAS in healthy neonates in the first 48 h of life. We performed one echocardiography in 30 neonates to assess feasibility and develop a standard protocol for image acquisition and analysis. LAS reservoir (LASr), conduit (LAScd) and contraction (LASct) were measured. We performed echocardiography at 24 and 48 h of life in an unrelated cohort of 90 neonates. Median (range) gestational age and weight of the first cohort were 34.4 (26.4–40.2) weeks and 2075 (660–3680) g. LAS feasibility was 96.7%. Mean (SD) gestational age and weight of the second cohort were 34.2 (3.8) weeks and 2162 (833) g. Mean (SD) LASr significantly increased from 24 to 48 h: 32.9 (3.2) to 36.8 (4.6). Mean (SD) LAScd and LASct were stable: −20.6 (8.0) and −20.8 (9.9), −11.6 (4.9) and −13.5 (6.4). Intra and interobserver intraclass correlation coefficient for LASr, LAScd and LASct were 0.992, 0.993, 0.986 and 0.936, 0.938 and 0.871, respectively. We showed high feasibility and reproducibility of LAS in neonates and provided reference ranges.
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6
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Telles F, McNamara N, Nanayakkara S, Doyle MP, Williams M, Yaeger L, Marwick TH, Leeson P, Levy PT, Lewandowski AJ. Changes in the Preterm Heart From Birth to Young Adulthood: A Meta-analysis. Pediatrics 2020; 146:peds.2020-0146. [PMID: 32636236 DOI: 10.1542/peds.2020-0146] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2020] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Preterm birth is associated with incident heart failure in children and young adults. OBJECTIVE To determine the effect size of preterm birth on cardiac remodeling from birth to young adulthood. DATA SOURCES Data sources include Medline, Embase, Scopus, Cochrane databases, and clinical trial registries (inception to March 25, 2020). STUDY SELECTION Studies in which cardiac phenotype was compared between preterm individuals born at <37 weeks' gestation and age-matched term controls were included. DATA EXTRACTION Random-effects models were used to calculate weighted mean differences with corresponding 95% confidence intervals. RESULTS Thirty-two observational studies were included (preterm = 1471; term = 1665). All measures of left ventricular (LV) and right ventricular (RV) systolic function were lower in preterm neonates, including LV ejection fraction (P = .01). Preterm LV ejection fraction was similar from infancy, although LV stroke volume index was lower in young adulthood. Preterm LV peak early diastolic tissue velocity was lower throughout development, although preterm diastolic function worsened with higher estimated filling pressures from infancy. RV longitudinal strain was lower in preterm-born individuals of all ages, proportional to the degree of prematurity (R 2 = 0.64; P = .002). Preterm-born individuals had persistently smaller LV internal dimensions, lower indexed LV end-diastolic volume in young adulthood, and an increase in indexed LV mass, compared with controls, of 0.71 g/m2 per year from childhood (P = .007). LIMITATIONS The influence of preterm-related complications on cardiac phenotype could not be fully explored. CONCLUSIONS Preterm-born individuals have morphologic and functional cardiac impairments across developmental stages. These changes may make the preterm heart more vulnerable to secondary insults, potentially underlying their increased risk of early heart failure.
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Affiliation(s)
- Fernando Telles
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.,Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia.,Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Shane Nanayakkara
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia.,Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia
| | | | | | - Lauren Yaeger
- Bernard Becker Medical Library, School of Medicine, Washington University in St Louis, St Louis, Missouri; and
| | - Thomas H Marwick
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Paul Leeson
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Philip T Levy
- Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Adam J Lewandowski
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom;
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7
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Levy PT, Jain A, Nawaytou H, Teitel D, Keller R, Fineman J, Steinhorn R, Abman SH, McNamara PJ. Risk Assessment and Monitoring of Chronic Pulmonary Hypertension in Premature Infants. J Pediatr 2020; 217:199-209.e4. [PMID: 31735418 DOI: 10.1016/j.jpeds.2019.10.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/28/2019] [Accepted: 10/11/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Amish Jain
- Department of Pediatrics, University of Toronto and Department of Pediatrics and Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Hythem Nawaytou
- Division of Cardiology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - David Teitel
- Division of Cardiology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Roberta Keller
- Cardiovascular Research Institute and the Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Jeffery Fineman
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Robin Steinhorn
- Department of Pediatrics, Children's National Health System, Washington, DC
| | - Steven H Abman
- Pediatric Heart Lung Center, Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA
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8
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Meinel K, Sallmon H, Koestenberger M. Right Ventricular Size and Function in Neonates after Use of Antidepressants during Pregnancy. Neonatology 2019; 116:191-192. [PMID: 31185472 DOI: 10.1159/000500526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 04/18/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Katharina Meinel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité - University Medical Center, Berlin, Germany
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria,
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9
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Méndez-Abad P, Zafra-Rodríguez P, Lubián-López S, Benavente-Fernández I. Myocardial Function Maturation in Very-Low-Birth-Weight Infants and Development of Bronchopulmonary Dysplasia. Front Pediatr 2019; 7:556. [PMID: 32010652 PMCID: PMC6978685 DOI: 10.3389/fped.2019.00556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/19/2019] [Indexed: 01/07/2023] Open
Abstract
Background: Myocardial function in very-low-birth-weight infants (VLBWIs) develops during early postnatal life, but different patterns of temporal evolution that might be related to the development of bronchopulmonary dysplasia (BPD) are not completely understood. Methods: A prospective cohort study including VLBWIs admitted to our NICU from January 2015 to 2017 was conducted. Plasma N-terminal pro B type natriuretic peptide (NTproBNP) levels were measured, and echocardiograms were performed at 24 and 72 h of life and weekly thereafter until 36 weeks of postmenstrual age (PMA). We measured the tricuspid annular plane systolic excursion (TAPSE) by M-mode; the lateral tricuspid E', A', and S' waves; and the myocardial performance index (MPI) by tissue doppler imaging (TDI). The subjects were divided into non-BPD and BPD groups. Results: We included 101 VLBWIs. The TAPSE and E', A', and S' waves increased while MPI-TDI decreased over time. Birth gestational age (GA) and postnatal PMA impacted these parameters, which evolved differently in those who developed BPD compared to those in the non-BPD group. The NTproBNP levels at 14 days of life and different echocardiographic parameters were associated with the development of BPD in different multivariate models. Conclusion: TAPSE and TDI values depend on GA and PMA and follow a different temporal evolution that is related to the later development of BPD. Combined biochemical and echocardiographic biomarkers can help identify which VLBWIs are at higher risk of developing BDP.
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Affiliation(s)
- Paula Méndez-Abad
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
| | - Pamela Zafra-Rodríguez
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
| | - Simón Lubián-López
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
| | - Isabel Benavente-Fernández
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
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10
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Nestaas E, Schubert U, de Boode WP, El-Khuffash A. Tissue Doppler velocity imaging and event timings in neonates: a guide to image acquisition, measurement, interpretation, and reference values. Pediatr Res 2018; 84:18-29. [PMID: 30072806 PMCID: PMC6257218 DOI: 10.1038/s41390-018-0079-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Neonatologists can use echocardiography for real-time assessment of the hemodynamic state of neonates to support clinical decision-making. There is a large body of evidence showing the shortcomings of conventional echocardiographic indices in neonates. Newer imaging modalities have evolved. Tissue Doppler imaging is a new technique that can provide measurements of myocardial movement and timing of myocardial events and may overcome some of the shortcomings of conventional techniques. The high time resolution and its ability to assess left and right cardiac function make tissue Doppler a favorable technique for assessing heart function in neonates. The aim of this review is to provide an up-to-date overview of tissue Doppler techniques for the assessment of cardiac function in the neonatal context, with focus on measurements from the atrioventricular (AV) plane. We discuss basic concepts, protocol for assessment, feasibility, and limitations, and we report reference values and give examples of its use in neonates.
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Affiliation(s)
- Eirik Nestaas
- 0000 0004 1936 8921grid.5510.1Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway ,0000 0004 0389 8485grid.55325.34Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway ,0000 0004 0627 3659grid.417292.bDepartment of Paediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Ulf Schubert
- 0000 0004 1937 0626grid.4714.6Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Willem P. de Boode
- grid.461578.9Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Nijmegen, The Netherlands
| | - Afif El-Khuffash
- 0000 0004 0617 7587grid.416068.dDepartment of Neonatology, The Rotunda Hospital, Dublin, Ireland ,0000 0004 0488 7120grid.4912.eDepartment of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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12
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Pediatric echocardiographic nomograms: What has been done and what still needs to be done. Trends Cardiovasc Med 2017; 27:336-349. [DOI: 10.1016/j.tcm.2017.01.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 12/29/2022]
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13
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Aye CYL, Lewandowski AJ, Lamata P, Upton R, Davis E, Ohuma EO, Kenworthy Y, Boardman H, Wopperer S, Packham A, Adwani S, McCormick K, Papageorghiou AT, Leeson P. Disproportionate cardiac hypertrophy during early postnatal development in infants born preterm. Pediatr Res 2017; 82:36-46. [PMID: 28399117 PMCID: PMC5511508 DOI: 10.1038/pr.2017.96] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/20/2017] [Indexed: 12/26/2022]
Abstract
BackgroundAdults born very preterm have increased cardiac mass and reduced function. We investigated whether a hypertrophic phenomenon occurs in later preterm infants and when this occurs during early development.MethodsCardiac ultrasound was performed on 392 infants (33% preterm at mean gestation 34±2 weeks). Scans were performed during fetal development in 137, at birth and 3 months of postnatal age in 200, and during both fetal and postnatal development in 55. Cardiac morphology and function was quantified and computational models created to identify geometric changes.ResultsAt birth, preterm offspring had reduced cardiac mass and volume relative to body size with a more globular heart. By 3 months, ventricular shape had normalized but both left and right ventricular mass relative to body size were significantly higher than expected for postmenstrual age (left 57.8±41.9 vs. 27.3±29.4%, P<0.001; right 39.3±38.1 vs. 16.6±40.8, P=0.002). Greater changes were associated with lower gestational age at birth (left P<0.001; right P=0.001).ConclusionPreterm offspring, including those born in late gestation, have a disproportionate increase in ventricular mass from birth up to 3 months of postnatal age. These differences were not present before birth. Early postnatal development may provide a window for interventions relevant to long-term cardiovascular health.
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Affiliation(s)
- Christina Y L Aye
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxfordshire, UK
| | - Adam J Lewandowski
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxfordshire, UK
| | - Pablo Lamata
- Department of Biomedical Engineering, King’s College London, London, UK
| | - Ross Upton
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxfordshire, UK
| | - Esther Davis
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxfordshire, UK
| | - Eric O Ohuma
- Centre for Statistics in Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Yvonne Kenworthy
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxfordshire, UK
| | - Henry Boardman
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxfordshire, UK
| | - Samuel Wopperer
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxfordshire, UK
| | - Alice Packham
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxfordshire, UK
| | - Satish Adwani
- Department of Paediatrics and Neonatology, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Kenny McCormick
- Department of Paediatrics and Neonatology, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Aris T Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, Oxfordshire, UK
| | - Paul Leeson
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxfordshire, UK,
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14
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Richardson C, Amirtharaj C, Gruber D, Hayes DA. Assessing Myocardial Function in Infants with Pulmonary Hypertension: The Role of Tissue Doppler Imaging and Tricuspid Annular Plane Systolic Excursion. Pediatr Cardiol 2017; 38:558-565. [PMID: 27995291 DOI: 10.1007/s00246-016-1548-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 12/02/2016] [Indexed: 01/19/2023]
Abstract
Transthoracic echocardiography is the most common noninvasive method of evaluating pulmonary hypertension (PH) in infants. Identification of reliable, quantitative indices of myocardial function may enhance the diagnostic value of echocardiography in this population. We hypothesized that pulsed wave tissue Doppler imaging (TDI) and tricuspid annular plane systolic excursion (TAPSE) would be reproducible measurements and would suggest decreased ventricular function, in infants with PH. This retrospective case-control study involved subjects diagnosed clinically and echocardiographically with PH at <12 months of age, matched with controls by age and gestational age (GA). TAPSE was measured by M-mode in the apical 4-chamber view. TDI velocities were averaged from three consecutive cardiac cycles. Observers were blinded to patient identity and clinical status. Fifty-seven subjects, including 35 term or near-term infants ≥35 weeks GA [mean GA 39 weeks (±1.7), median age 1 day (range 0-2)] and 22 preterm infants [median GA 25.4 weeks (24.1-26.6), age 66 days (4-128)], were matched with 57 controls. Subjects with PH had lower TAPSE (term p < 0.001, preterm p = 0.03) and TAPSE indexed to body surface area (term p < 0.001, preterm p = 0.005). Mitral annular, septal, and tricuspid annular systolic (S') and early diastolic (E') TDI velocities were also decreased compared to controls (all p < 0.05). Intraclass correlation demonstrated 84-99% agreement between observers in measuring TDI and 92% for TAPSE. Intraobserver reliability for these measures was 98-99% and 96%, respectively. We concluded that TDI and TAPSE are reproducible indices of myocardial function and may serve as useful adjuncts to standard echocardiographic measures in infants with PH.
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Affiliation(s)
- Chalese Richardson
- Division of Pediatric Cardiology, Cohen Children's Medical Center, 269-01 76th AvenueSuite 139, New Hyde Park, NY, 11040, USA
| | - Cynthia Amirtharaj
- Division of Pediatric Cardiology, Cohen Children's Medical Center, 269-01 76th AvenueSuite 139, New Hyde Park, NY, 11040, USA
| | - Dorota Gruber
- Division of Pediatric Cardiology, Cohen Children's Medical Center, 269-01 76th AvenueSuite 139, New Hyde Park, NY, 11040, USA
| | - Denise A Hayes
- Division of Pediatric Cardiology, Cohen Children's Medical Center, 269-01 76th AvenueSuite 139, New Hyde Park, NY, 11040, USA.
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Murase M. Assessing ventricular function in preterm infants using tissue Doppler imaging. Expert Rev Med Devices 2016; 13:325-38. [DOI: 10.1586/17434440.2016.1153966] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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16
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Morales-Roselló J, Khalil A, Perales-Marín A. Fetal tricuspid annulus plane systolic excursion (fTAPSE) at term – association with cerebroplacental ratio, birthweight and neonatal pH. J Matern Fetal Neonatal Med 2015; 29:1636-41. [DOI: 10.3109/14767058.2015.1057810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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17
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Grangl G, Haidl H, Koestenberger M. Relevance of tissue Doppler imaging for assessment of right ventricular performance in preterm neonates. Early Hum Dev 2015; 91:307. [PMID: 25827637 DOI: 10.1016/j.earlhumdev.2015.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/17/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Gernot Grangl
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Austria
| | - Harald Haidl
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Austria
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Austria.
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Longitudinal systolic left ventricular function in preterm and term neonates: reference values of the mitral annular plane systolic excursion (MAPSE) and calculation of z-scores. Pediatr Cardiol 2015; 36:20-6. [PMID: 25077661 DOI: 10.1007/s00246-014-0959-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 06/20/2014] [Indexed: 10/25/2022]
Abstract
The mitral annular plane systolic excursion (MAPSE) is a quick and reliable echocardiographic tool for assessing longitudinal left ventricular (LV) systolic function in children and adults. Because this parameter is affected by the LV longitudinal dimension, pediatric and adult normal values are not suitable for preterm and term neonates. A prospective study investigated a large group of preterm and term neonates [gestational age (GA), 26/0-6 to 40/0-6; birth weight (BW), 670-4,140 g]. The growth- and BW-related changes in MAPSE were determined to establish normal z-score values for preterm and term neonates. The MAPSE ranged from a mean of 0.36 ± 0.05 cm in preterm neonates with a GA of 26/0-6 to 0.56 ± 0.08 cm in term neonates with a GA of 40/0-6. The findings showed MAPSE, GA, and BW to be moderately correlated. Pearson's correlation coefficient was 0.56 for GA (MAPSE; p < 0.001) and 0.58 for BW (MAPSE; p < 0.001). The normal MAPSE values did not differ significantly between females and males (p = 0.946). The absolute values and z-scores of normal MAPSE values in healthy preterm and term neonates within the first 48 h of life were calculated, and percentile charts were established. Determination of LV function using MAPSE might be useful for vulnerable infants for whom a prolonged examination is inappropriate and for neonates with suboptimal visualization of the endocardium.
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James AT, Corcoran JD, Jain A, McNamara PJ, Mertens L, Franklin O, El-Khuffash AF. Assessment of myocardial performance in preterm infants less than 29 weeks gestation during the transitional period. Early Hum Dev 2014; 90:829-35. [PMID: 25463828 DOI: 10.1016/j.earlhumdev.2014.09.004] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 09/03/2014] [Accepted: 09/07/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND The transitional circulation and its effect on myocardial performance are poorly understood in preterm infants. AIMS We assessed myocardial performance in infants less than 29 weeks gestation in the first 48 h of life using a comprehensive echocardiographic assessment. DESIGN Infants <29 weeks gestation were prospectively enrolled. Small for gestation, infants on inotropes and/or inhaled nitric oxide and septic infants were excluded. Conventional echocardiography, left ventricular (LV), septal and right ventricular (RV) tissue Doppler imaging (TDI) and tissue Doppler-derived strain and strain rate (SR), tricuspid annular plane systolic excursion (TAPSE) and global RV fractional area change (FAC) were assessed at a median of 10 and 45 h post-delivery. RESULTS Fifty-four infants with a median [IQR] gestation and birth weight of 26.5 weeks [25.8-28.0 weeks] and 915 g [758-1142 g] were included. There was no change in shortening or ejection fraction across the two time points. Systolic and diastolic TDI of the LV, septum and RV increased across the two time points (all p values ≤ 0.01). There was an increase in septal peak systolic and early diastolic SR (p=0.002). Septal systolic strain and late diastolic SR did not change. With the exception of RV strain and early diastolic SR, all RV functional parameters including SR, late diastolic SR, TAPSE, and FAC increased across the two time points (all p values<0.01). CONCLUSION Describing the normal hemodynamic adaptations in stable preterm infants during the transitional period provides the necessary information for the assessment of those parameters in various disease states.
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Affiliation(s)
- Adam T James
- Department of Paediatrics, The Rotunda Hospital, Dublin, Ireland
| | - John D Corcoran
- Department of Paediatrics, The Rotunda Hospital, Dublin, Ireland
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Canada; Department of Physiology, University of Toronto, Toronto, Canada; Physiology and Experimental Medicine, Hospital for Sick Children, Toronto, Canada
| | - Patrick J McNamara
- Physiology and Experimental Medicine, Hospital for Sick Children, Toronto, Canada; Department of Neonatology, The Hospital for Sick Children, Toronto, Canada
| | - Luc Mertens
- The Labatt Family Heart Centre, The Hospital for Children, Toronto, Canada
| | - Orla Franklin
- Department of Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Afif F El-Khuffash
- Department of Paediatrics, The Rotunda Hospital, Dublin, Ireland; Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland.
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Jain A, Mohamed A, El-Khuffash A, Connelly KA, Dallaire F, Jankov RP, McNamara PJ, Mertens L. A comprehensive echocardiographic protocol for assessing neonatal right ventricular dimensions and function in the transitional period: normative data and z scores. J Am Soc Echocardiogr 2014; 27:1293-304. [PMID: 25260435 DOI: 10.1016/j.echo.2014.08.018] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is a paucity of echocardiographic data describing right ventricular (RV) dimensions and function in the early transitional newborn period. METHODS Fifty healthy term newborns underwent serial echocardiography at a mean of 15 ± 2 and 35 ± 2 hours of age. RV dimensions and functional indices were measured as recommended in the American Society of Echocardiography's recent guidelines. Additional novel parameters included RV anteroinferior basal diameter, fractional area change (FAC) from the apical three-chamber view, and speckle-tracking echocardiography-derived peak longitudinal strain in the RV lateral (apical four-chamber view) and inferior (apical three-chamber view) walls. Results obtained at both time points were compared. RESULTS Linear dimensions and tissue Doppler velocities were highly reproducible, while time intervals and FAC measurements were more variable. Three-chamber FAC was higher than four-chamber FAC (36 ± 5% vs. 24 ± 7%, P < .001). Lateral wall peak longitudinal strain was similar to the value for the inferior wall (22 ± 4% vs 18 ± 5%, P > .05). A small increase in RV dimensions was noted on day 2 of life (midcavity diameter, 1.71 ± 0.19 vs 1.55 ± 0.19 cm, P < .01; RV anteroinferior basal diameter, 2.24 ± 0.29 vs 2.06 ± 0.24 cm, P < .01; end-diastolic-area in the apical four-chamber view, 4.32 ± 0.64 vs 4.10 ± 0.69 cm(2), P = .04), while no changes occurred in functional indices. RV dimensions and FAC showed moderate linear correlations with birth weight. Z scores could be computed for the majority of measured indices. CONCLUSIONS Using conventional and novel indices, the investigators describe a comprehensive echocardiographic protocol for neonatal RV imaging, establish reference ranges, and describe the effect of physiologic postnatal transition on RV dimensions and function. This will facilitate future investigations of RV dysfunction in neonatal cardiopulmonary disorders.
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Affiliation(s)
- Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada.
| | - Adel Mohamed
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | | | - Kim A Connelly
- University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, Toronto, Ontario, Canada
| | - Frederic Dallaire
- The Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert P Jankov
- University of Toronto, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada; Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, Toronto, Ontario, Canada; Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patrick J McNamara
- University of Toronto, Toronto, Ontario, Canada; Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luc Mertens
- University of Toronto, Toronto, Ontario, Canada; Division of Pediatric Cardiology, Faculty of Medicine, University of Sherbrooke, and Centre de Recherche Clinique Étienne-Le Bel, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
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Eriksen BH, Nestaas E, Hole T, Liestøl K, Støylen A, Fugelseth D. Myocardial function in term and preterm infants. Influence of heart size, gestational age and postnatal maturation. Early Hum Dev 2014; 90:359-64. [PMID: 24794303 DOI: 10.1016/j.earlhumdev.2014.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 03/24/2014] [Accepted: 04/08/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Sparse knowledge exists on the differences in cardiac function between term and preterm infants. This study examines the impact of heart size, gestational age and postnatal maturation on myocardial function. AIM To assess and compare serial echocardiographic indices of myocardial function in term and moderately preterm infants. METHODS Longitudinal, prospective, observational echocardiographic cohort study of 45 healthy term infants examined at day three and at 12-20weeks postnatal age and 53 moderately preterm infants (gestational age 31-35weeks) examined at day three and at term equivalent (4-10weeks postnatal age). OUTCOMES Primary: Systolic mitral and tricuspid annular plane excursions and annular peak systolic pulsed wave tissue Doppler (pwTDI) velocities. Secondary: Indices normalized for heart size. RESULTS On day three, all indices were higher in the term than in the preterm infants whereas normalized systolic pwTDI velocities were lower in the term infants and normalized excursions showed no difference. All indices increased with advanced postnatal age. The indices in term infants on day three were lower than in preterm infants at term equivalent, with and without normalization. After postnatal maturation in both groups, all indices were higher in the term group (except left pwTDI), whereas normalized indices showed no consistent pattern. CONCLUSIONS Myocardial function indices increased with gestational age at birth and more profoundly with postnatal maturation. Serial examinations of non-normalized and normalized myocardial function indices showed no sustained differences between the preterm and the term infants. Normalization by heart size may be of value when assessing myocardial function in infants.
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Affiliation(s)
- Beate Horsberg Eriksen
- Department of Paediatrics, Møre and Romsdal Hospital Trust, NO-6026 Ålesund, Norway; Department of Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Eirik Nestaas
- Department of Paediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Torstein Hole
- Department of Medicine, Møre and Romsdal Hospital Trust, Ålesund, Norway; Institute of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Knut Liestøl
- Institute of Informatics, University of Oslo, Norway
| | - Asbjørn Støylen
- Department of Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Cardiology, St. Olavs Hospital, Trondheim, Norway
| | - Drude Fugelseth
- Department of Neonatal Intensive Care, Oslo University Hospital, Ullevål, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Saleemi MSH, El-Khuffash A, Franklin O, Corcoran JD. Serial changes in myocardial function in preterm infants over a four week period: the effect of gestational age at birth. Early Hum Dev 2014; 90:349-52. [PMID: 24796208 DOI: 10.1016/j.earlhumdev.2014.04.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 04/07/2014] [Accepted: 04/12/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Myocardial performance is impaired in the first days of life in preterm infants but improves by day 5. Tissue Doppler imaging (TDI) is a novel and reliable means of assessing myocardial performance. OBJECTIVE To investigate myocardial performance using TDI and shortening fraction (SF) in preterm infants of different gestational age groups and serial changes in these parameters in first four weeks of life. Study design Infants less than 36 weeks of gestation were divided into group 1 (24-27 weeks, n=8), group 2 (28-31 weeks, n=12) and group 3 (32-35 weeks, n=13). Infants with severe congenital malformations, a hypoxic insult at birth, and those on inotropic support were excluded. Echocardiograms were performed at 36-48 hours, 2 weeks and 4 weeks of life. Left ventricular (LV) SF, systolic (S'), early diastolic (E') and late diastolic (A') TDI velocities were assessed. We analyzed the data using a repeated-measures ANOVA. RESULTS Thirty three infants underwent serial TDI and SF measurements. There was an increase in LV S' (p=.02) and E' (.01) velocities in group 2 , and in group 3 (p=.03 for S' and p=.04 for E'), but no significant increase in group 1 (p=.48 for S' and .32 for E'). At each study point, there was significant difference in myocardial performance between group 1 and 3 for each of the parameters (p<.05). There was no significant increase in SF over time in any of the groups. CONCLUSION We describe a serial increase in myocardial performance in infants of 28 weeks gestation and above. While there was no change in myocardial performance among the most extremely preterm infants, this may have been the result of small sample size of the group.
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Affiliation(s)
| | | | - Orla Franklin
- Department of Cardiology, Children's University Hospital, Temple Street, Dublin, Ireland
| | - John David Corcoran
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland; Department of Paediatrics, Trinity College University, Dublin, Ireland
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Gores G, Raith W, Ravekes W, Koestenberger M. Relevance of longitudinal systolic heart function in fetuses with intrauterine growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:108-109. [PMID: 24395689 DOI: 10.1002/uog.13260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 11/22/2013] [Indexed: 06/03/2023]
Affiliation(s)
- G Gores
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Auenbruggerplatz 30, A-8036, Graz, Austria
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24
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Koestenberger M, Raith W, Ravekes W. Importance of quantifiable right heart systolic function evaluation using tricuspid annular plane systolic excursion (TAPSE) in fetuses and neonates. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:367. [PMID: 24000159 DOI: 10.1002/uog.12530] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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